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evaluation. Please review the Power Points from this document. If you would like a
print out of this Enduring Material, Please contact Lori Graham (x4050) or Jayne
Sheehan (x4052). Thank you!
Dear Physician:
Physician education/training for a review of pain management is now available. This will
involve:
Thank you,
07/09
rsharesoncmeendmatpainmanagement
ENDURING MATERIAL
Chronic pain is a complex disease affecting more individuals than diabetes, heart disease, and cancer
combined. There are approximately eighty million sufferers and it is the most common reason to seek
medical help.
Description:
This four hour comprehensive review course on pain management is intended to describe and define the
various types of pain that a primary care physician is confronted with on a regular basis. The course will
offer methods to proper diagnosis and various aspects of pain management. In order to provide better
outcomes with reduced side effects, the standard of care issues, protocols, schedules, and suggestions on
timely transfer of care issues will be reviewed.
Objectives:
After this course, participants should be able to:
1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
2. Describe the various methods of multidisciplinary pain management, including
alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain
management, including side effects, abuse, governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score.
Pain Management
To receive CME credits for this test, you must mark your answers,
complete the evaluation/enrollment information, and return them in
the envelope provided to Jayne Sheehan or Lori Graham.
Accreditation Statement
Designation Statement
Disclosure Statement
All Faculty and CME Committee do not have any real or apparent
conflict(s) of interest or other relationships related to the content of
this presentation.
True or False
Multiple Choice
12. TCAs are effective for the treatment of low back pain,
neuropathic pain, and migraine. Which of the following
commonly limits their use?
a. Cost
b. Potential for addiction
c. Formulary restrictions
d. Anti-cholinergic side effects
13. Nonselective NSAIDS are not recommended for preemptive
Analgesia because________________________.
a. they are ineffective
b. prolonged clotting times are a concern
c. no intravenous formulations are available
d. postoperative nausea and vomiting are possible
Learning Objectives: At the conclusion of the presentation, the participant should be able to:
1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
2. Describe the various methods of multidisciplinary pain management, including alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain management, including side effects, abuse,
governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score
Please rate the following… Excellent Good Fair Poor
Overall activity…
Clarity of session content…
Relevance of content to you…
Quality of visual aids/handouts…
Presenter’s overall performance…
Presenter’s knowledge of subject area…
Presenter’s presentation skills…
Presenter’s ability to respond to questions…
Location of CME activity…
Statement of changes this program has made on your practice.
Some questions allow for more than one answer.
If you answered Disagree or Strongly Disagree to any of the statements above, please explain your disagreement with
the statement(s) in space below. Any other comments about today’s program can be made here also.
{ Recent Development
Recent Developments in Pain Management
` Short-lived
Pain from : 1. Recent Surgery
2. Recent Injury
3. Medical Illness
` NSAID’S
` Opioids
Side effects:
` Intense sedation
` Respiratory Depression
` Urinary retention
` Inhabition of bowel function
Regional Anesthesia
1. Continuous epidural infusion of local anesthetic
` Acetaminophen (Tylenol)
5. Edema
6. Hypertension
Cylo-oxygenase (COX) inhibitors
` Are effective analgesics in both inflammatory
and surgical conditions
` Decrease opiod reqirements by 30%-50%
` Fentanyl ` Oxycodone
` Morphine (MS ` Oxycontin(oxycodone)
Contin)(15-30 mg po -2 times more potent
q8-12hrs) than morphine
` Dosage
` Avinza – once daily (10,15,20,30,40,60,80
dosing(30,45,60,75,90 ER)
,120 ER) ` No active metabolites
` Methadone - ` Used in opioid tolerant
inexpensive mu patients
agonist
` Duration 6-8 hours
` 2-4 times more potent
than morphine
` Morphine-like
drugs prescribe d
to treat acute pain ` Hydrocodone with
or cancer pain acetaminophen
(Vicodan, Lortab,
Norco)
` Acetaminophen
with codeine
(Tylenol#3,etc.)
` Duragesic transdermal skin patch- narcotic
treatment for moderate to severe chronic pain
` Fentanyl delivery for 72 hours
` 25 mcg/hr patch ~60 mg per day morphine
` Dependence,abuse
` Allows patient to self administer an analgesic
agent
` Incremental dose, lockout interval, maximum
dose mg/hr and optional basal rate
` Preferred to use incremental dose of opioid
with short lockout interval to allow frequent
dosing ie, morphine 1.5 mg Q 8 min ; 12
mg/hr max.
` Basal rate usually used only following
extensive and extremely painful surgery
` Has been demonstrated to result in improved
patient satisfaction due to decreased delay in
treatment
Ultram(Tramadol)
2) Epidural abscess
3) Epidural hematoma
` Group of nerves or single nerve causing pain
• For Physicians?
• For Patients?
Proper Opiate Prescribing
Guidelines
What are the differences between dependence, tolerance,
addiction and pseudo-addiction?
How should the patient taking long-term opiate medication for
chronic non-malignant pain be managed?
• Treatment options?
What are the requirements necessary to either discontinue
prescription narcotic use or discharge a patient for either abuse
or diversion?
Proper Opiate Prescribing
Guidelines
When is prescribing appropriate?
y Acute pain : Pain that comes on quickly, can be severe,
but lasts a relatively short time. As opposed to chronic
pain.
y Chronic pain: Pain (an unpleasant sense of discomfort)
that persists or progresses over a long period of time. In
contrast to acute pain that arises suddenly in response to
a specific injury and is usually treatable, chronic pain
persists over time and is often resistant to medical
treatments.
y Pitfall: How can physicians be certain that a patient’s
pain is legitimate and that the painful condition warrants
the use of narcotics?
Proper Opiate Prescribing
Guidelines
What information is necessary before prescribing?
y More important for patient’s requiring chronic
opiate management.
y What does the patient’s history & physical
examination show?
y What is documented in diagnostic testing records?
y What documentation is appropriate? (Above, plus
pharmacy records, urine drug screen)
Proper Opiate Prescribing
Guidelines
Federal law does not preclude the use of opioid’s as analgesics for
legitimate medical purposes, including treating chronic pain and
treating pain in addicts.
y Addiction
y Pseudoaddiction
Proper Opiate Prescribing
Guidelines
Tolerance: decrease in
susceptibility to the effects
of a drug due to its continued
administration.
Proper Opiate Prescribing
Guidelines
yADDICTION: drug addiction, a condition
characterized by an overwhelming desire to continue
taking a drug to which one has become habituated
through repeated consumption because it produces a
particular effect, usually an alteration of mental
status. Addiction is usually accompanied by a
compulsion to obtain the drug, a tendency to increase
the dose, a psychologic or physical dependence, and
detrimental consequences for the individual and
society.
y Mosby's Medical Dictionary, 8th edition. © 2009,
Elsevier.
Proper Opiate Prescribing
Guidelines
y Pseudoaddiction: Pattern of drug seeking behavior
of pain patients receiving inadequate pain
management that can be mistaken for addiction
y Cravings and aberrant behavior
y Concerns about availability
y “Clock-watching”
y Unsanctioned dose escalation
**Can be distinguished from true addiction in that
the behaviors resolve when pain is effectively
treated.
Proper Opiate Prescribing
Guidelines
How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
y Monthly evaluations
y Random urine drug screens & pill counts
y Pain Management Agreement
y Opiate Informed consent
Proper Opiate Prescribing
Guidelines
How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
• Treatment options?
9 Poly-pharmacy, inclusive of NSAIDS, muscle relaxants,
anti-convulsants, anti-depressants (TCA’s, SSRI’s,
SNRI’s), opiates, etc…
9 Physical therapy
9 Occupational therapy
9 Psychiatric therapy
9 Cognitive-behavioral therapy
9 Surgical intervention
Proper Opiate Prescribing
Guidelines
What are the requirements necessary to either
discontinue prescription narcotic use or discharge a
patient for either abuse or diversion?
y Repeated phone calls to the office requesting early
narcotic refills.
y Unusual excuses to explain loss, theft or damage to
narcotic medication.
y Tainted urine drug screens.
Proper Opiate Prescribing
Guidelines
Continued discharge criteria:
y Incorrect pill count
y Evidence of Doctor Shopping
Proper Opiate Prescribing
Guidelines
Physician obligation to patient:
If discontinuing opiates only:
9 letter outlining to the patient of such necessity
If discharging a patient:
9 Letter of discharge if patient being released from
practice
9 Offer patient opportunity to attend rehab
9 One month supply of discharge or withdrawal medication
Proper Opiate Prescribing
Guidelines
Conclusion:
It is often appropriate and necessary to prescribe
narcotic based medications. As long as these
guidelines are adhered to, physicians may
prescribe them without fear of disciplinary action
or prosecution.
Chronic Intractable Pain and
Opioids:
Relieve suffering
Avoid addiction
Limit liability
Thomas A Ranieri MD, FIPP, DABIPP
Allied Pain Treatment Centers
Disclosures
I, Thomas Ranieri, have no conflict of interest in
relation to this presentation.
Prescribing Controlled Drugs
A Question of Balance
“The under-prescribing of controlled drugs
for acute, chronic and malignant pain, and
(perhaps) anxiety is extremely widespread
and contributes to significant patient
morbidity.”
80,000
70,000 Treatment
60,000 Admissions
50,000
40,000
30,000
1995 1996 1997 1998 1999 2000 2001 2002
Unintentional Drug Poisoning
Paulozzi et al. – Pharmacoepidemiol Drug Saf. 2006 15(9):618-627
Average Mortality Increased
5%/year from 1979-1990
18%/year from 1990-2002
Opioid poisoning vs. Cocaine, Heroin from 1999-2002
91% inc. with Opioids
33% inc. with Cocaine
12% inc. Heroin
2002 Statistics
32% Methadone
54% other opioids
13% synthetic Opioids
Number of new non-medical
users of therapeutics
(NSDUH,
2002)
Drug Abuse: An Epidemic
Current illicit drug use in 2006(1 mo. Prior to survey) NSDUH Survey
Among Populations aged 12 or older
20.4 million Americans or 8.3% of population
Nearly 8,000 initiates per day
Among population aged 12 o 17
9.8% of population
Among population aged 18 or older
18.5 million current users
13.4 million (74.9%) employed part or full time
Lifetime use – 111.8 million
Past year – 35.8 million
Illicit drug use other than marijuana
Life time 72.9 million
Past year 21.3 million
Current 9.6 million
Chronic intractable pain: the
clinical challenge
THEN…..
CURE SOMETIMES
Prescribing Controlled Drugs
The Doctors
Pitfalls
“I just don’t prescribe any controlled drugs in my
practice”
“If patients abuse their medications, that is their
problem not mine”
“I only prescribe controlled drugs in extreme
situations, and only if pushed”
Chronic Pain Management:
decisions regarding chronic opioid
therapy
Narrow toxic/therapeutic
YES! UNSURE NO
Re-document: Physical Dependence vs Addiction: Educate patient
Chemical dependence on need to
Diagnosis discontinue opioids
screening
Work-up
Toxicology tests
Treatment goal Emergency?
Pill counts
Functional status ie: overdoses
Monitor for scams selling meds
Reassess for altering Rx
Monitor Progress: appropriateness
Pill counts
NO!
Function YES! 3-month self taper
Refill flow chart (document in chart)
Occasional urine Discontinue opioids OK
toxicology Instruct patient on 10-week structured taper
Adjust medications withdrawal symptoms OK
Watch for scams Tell to “go to ER” Discontinue opioids at
if withdrawal symptoms end of structured taper
Opioid w/d treatment options
Gradual self taper over three months**
10 week structured taper**
Abrupt discontinuation and detoxification
Methadone
Clonidine
Buprenorphine
Tramadol
Ultra-Rapid Opiate Detoxification – Consent &
Compliance
** = non-emergency patient with a legitimate pain diagnosis.
Chronic intractable pain: the
clinical challenge
Be aware of the “Heart Sink” patient.
Remain within your area of expertise.
Stay grounded in you role
Utilize Interventional Pain Physician for
Diagnostic/Differential - Injections/Infusions
FIRST….DO NO HARM
THEN…..
CURE SOMETIMES
COMFORT ALWAYS
Pain Management for
the Non-Specialist
Presented by:
z Clinical Features
- the setting; the first clue
- the distribution; follows the nerve distribution
- the character; burning, shooting, stabbing
- findings of physical examination: numbness,
coolness, and allodynia
Muscle Pain
z Causes
- muscle pain of chronic pain
- fibromyalgia syndrome and,
- myofascial pain syndrome
z Common Clinical Features
- sore, stiff, aching, painful muscles
- fatigue, poor sleep, depression, headache,
and irritable bowel syndrome
- acute muscle pain occasionally
- pain related disability is a challenge to the
health care system
z Fibromyalgia Syndrome
- Widespread musculoskeletal disease
z Clinical Features
- heat, redness, and swelling
Mechanical / Compression Pain
z Causes : muscle / ligament strain,
degeneration of discs, facets or
osteoporosis with compression fractures,
fractures, dislocation, obstruction, and
compression by bony tumors
z Same as nociceptive pain
z Aggravated by activity and usually
relieved rest
z Radiology very helpful
Pain Management -Algorithm
z Develop a written plan of care and set
goals using the bio-psychosocial model
z All patients with chronic pain must
participate in an exercise fitness program
z Set personal goals/restructuring life
z Improve sleep, manage stress
z Decrease pain
z Patients want quick fix, not temporary
relief
Treatment Plan for Chronic Pain
z Rehabilitation/functional management
z Psychosocial management
- Depression
- Cognitive – Behavior therapy
z Pharmacologic management
z Interventional management
z Non-pharmacologic management
z Complementary medicine
z Referral to multi-disciplinary pain mgmt.
z Surgery for placement of a stimulator or
pump
Management of Neuropathic Pain
z Eliminate the underlying causes of pain
z Local or regional therapies
- Topical Capsaicin, 3 to 4 times daily
- Lidocain cream or patch
- Transcutaneous electrical nerve stimulator
z Pharmacologic management
- Gabapentin: 300mgs TID (100% Renal)
- Pregabalin: 50-100 mgs TID
- Other Anticonvulsants:
* Carbamazepine
* Oxcarbazepine 150-300 mgs BID
* Topiramate, Lamotrigine, Tiagabine
* Benzodiazepine, Clonazepam
Pharmacologic Management
(cont)- Neuropathic Pain
z Tricyclic antidepressants
- Amitriptyline, Notriptyline, Desipramine,
Imipramine, and others
- Potentiate descending inhibitory pathways
- Pain reduction is independent of effect
on depression
- A screening EKG is required in elderly
z Corticosteroids
- Pain relief through membrane stabilization
and anti-inflammatory effects
- Short term control of neuropathic radicular
pain caused by edema, tumor invading
bone and acute or sub-acute disc herniation
z Opioids
- not known for neuropathic pain but as potent
analgesics
- Methadone and Tramadol are more effective
Management of Muscle Pain
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Cyclobenzaprine
- Depression and Pain
* Duloxetine
- Opioids rarely needed
Inflammatory Pain Management
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Carbobenzaprine (short term)
- Depression and pain
* Duloxetine
- NSAIDS, immunologic drugs, other
depressants
Mechanical / Compressive
Pain Management
z Screen for serious medical pathology and
refer to appropriate specialist
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Tricyclic antidepressants
- NSAIDS
- Other antidepressants
Pharmacologic Management of Pain
Key Points
z A thorough medication history is critical
z Base the choice of medications on type and
severity
z Medications are not the primary focus in managing
pain
z Titrate doses for an optimal balance between
analgesic benefit, side effects, and functional
improvement
z For Opioid therapy:
- use a written Opioid agreement for long-
term therapy
- see the Federation of State Medical
Boards at:
http://www.fsmb.org for complete
information
Non-Opioid Analgesics
Acetaminophen
z To treat mild chronic pain or to supplement
z Lack anti-inflammatory effects
z Do not damage gastric mucosa
z May have chronic renal and hepatic side
effects
z Dose; max 4gms./24 hrs.
z Caution: Patients with liver impairment
Non-Opioid Analgesics,
Non-Steroidal Anti-Inflammatory Drugs
z To treat mild to moderate inflammatory or
non-neuropathic pain
z NSAIDS inhibit prostaglandin synthesis by
blocking the enzyme Cyclooxygenase (COX)
z COX-2 agents have fewer GI symptoms but
higher cardiovascular effects. Use along
with gastroprotective agent; Proton pump
inhibitor (Misoprostol)
z Use caution in patients with risk of bleeding
z Ketorolac not for chronic pain
z NSAIDS have significant opioid sparing
properties and reduce opioid-related side
effects
Use of Opioids in Chronic Pain
z First get familiar with Federation of State
Medical Board documents
z For neuropathic pain, not responding to first line
therapies
z Opioids are rarely beneficial for inflammatory,
mechanical / compressive pain
z Not indicated for chronic headache mgmt.
z Have better therapeutic index and low medical
risks
z Close monitoring is essential and non-compliant
pts. must be referred to pain or addiction
specialist
Tricyclic Anti-Depressants
(TCAS)
z First line for neuropathic pain with insomnia,
anxiety and depression
z Avoid tertiary amines (Amitriptyline,
Imipramine)
z TCAS analgesic effects are with lower doses
z Maximum analgesic effect may take several
weeks to be seen
z Baseline EKG is indicated for pts. at higher
cardiac risk
z Common side effects: sedation, dry mouth,
constipation, and urinary retention
Other Anti-Depressants
z Selective Serotonin re uptake inhibitors
z Less side effects compared to TCAS, but
less efficient for neuropathic pain relief
z Bupropion, Venlafaxine, and Duloxetine
are all efficient against neuropathic pain
z Duloxetine in doses of 60 mgs. BID is
beneficial for fibromyalgia
Anticonvulsant or Antiepileptic
Drugs
z Carbamazepine and Phenytoin:
- effective for neuropathic pain
- Carbamazepine well established for
trigeminal neuralgia
- unwanted CNS side effects
z Pregablin:
- Diabetic neuropathy
- Post herpetic neuralgia
z Oxcarbazepine; good for neuropathic pain
Physician Date/Time
*Patients in terminal state may be exempt from these monitoring/intervention orders. Physician can cross out
unapplicable orders and initial to eliminate this monitoring.
Physician Date/Time
Physician Date/Time
Physician Date/Time
Physician Date/Time